Examining the different types of Original Medicare coverage

Retirement Planning
1. Most Americans over the age of 65 have the ability to enroll in Medicare part A and Medicare part B. Medicare Part A is what is known as “hospital insurance”, and “helps pay for inpatient care in a hospital or limited time at a skilled nursing facility (following a hospital stay). Part A also pays for some health care and hospice care”, according to the Social Security Administration.
The Medicare website outlines some specific things within each of these broad categories. For example, under hospital care Medicare Part A covers semi-private rooms, meals, general nursing, drugs as part of your inpatient treatment, and other hospital services and supplies.
In a skilled nursing care unit, you are covered for meals, semi-private room, skilled nursing care, physical therapy, occupational therapy, speech-language pathology services, medications, medical social services, medical supplies and equipment used in the facility, ambulance transportation, dietary counseling, and swing bed services. In long-term care hospitals, there is some coverage under Part A, but there are also very high fees that need to be paid as co-pay, so this category is not particularly well-covered under Part A
For home health services, Part A covers a fairly extensive range of services, including part-time skilled nursing care, physical therapy, occupational therapy, speech-language pathology services, medical social services and part-time home health aide services. It is important to understand the limitations of this care, because it does not cover things like meals delivered to your home (unlike when you are in a medical facility and they feed you), and it doesn’t care full-time care or personal care.
It is also worth noting that these are the minimum levels of what can be covered, and each state might supplement these with additional coverage. That will be established on a state-by-state basis.
2. Medicare Part B is what is known as “medical insurance”. This includes things like clinical research, ambulance services, durable medical equipment, mental health (inpatient & outpatient), and limited outpatient prescription drugs.
Within these, there are details provided by the Medicare.gov website. For example, under clinical research the patient pays 20% of the cost, but this allows them to participate in clinical research trials such as diagnostic tests, surgical treatments, medicine and new types of patient care.
Part B’s ambulance coverage includes “ground ambulance transportation when you need to be transported to a hospital, critical access hospital or skilled nursing facility for medically necessary services and transportation in any other vehicle could endanger your health.”
Durable medical equipment coverage provides for a wide range of medical equipment that you may need. Mental health care is provided for to some extent, but with massive co-pays and eventually you will pay all costs. Under the category of “limited outpatient prescription drugs” there are drugs used with medical equipment, antigens, and a few other types of drugs for outpatient usages. But Part B is not really intended to provide comprehensive prescription drug coverage – that’s Part D.
What’s odd is that actual health care isn’t discussed on the Medicare page – like if you need surgery is that covered? Seems like a pretty big thing to not talk about. It appears that “Medicare covers many medically necessary surgical procedures” but whether this coverage applies to a particular course of care, and how much is actually covered, will vary substantially, and that is why there is little information provided on the Medicare website.
3. If Gaye suffers a severe fall and spends 100 days in hospital, it is not possible to determine exactly who much she’ll have to pay. First, the exact costs of whatever she needs aren’t known. Second, the choice of what facility type appears to make a difference. Part B covers the doctor services, and most of the other basics that Gaye might need like semi-private room and meals, the ambulance to get her to the hospital. It looks like most of what she receives during that 100 days will be covered.
However, Gaye will be responsible for any extras, but also may be responsible for any equipment that she needs once she leaves hospital. She’ll be covered for the physical therapy, but if she needs walkers, crutches or wheelchair. There are some factors that matter, but she’d pay 20% of the Medicare-approved amount for this equipment at home once released from the hospital.
It appears, however, that Gaye will not pay much out of pocket while in hospital, at least not for basic care, as Medicare Part A covers basic hospital costs, and Medicare Part B covers medical costs. Only once she is released from hospital will she be subject to costs that are less predictable, and much higher. But if she arrives at the emergency department after the fall and is admitted, Parts A and B provide most of the coverage as an inpatient. She will be an outpatient on the last day, however, and should be aware that the coverage for outpatients is a little bit different.
4. In general, Medicare does not pay coverage for medical services outside of the United States and its territories (Puerto Rico, US Virgin Islands, American Samoa, Guam and Northern Mariana Islands).
For situations where Medicare does cover costs incurred outside of the United States, those situations are limited to an “emergency that requires immediate medical attention to prevent disability or death”, a situation that is unlikely to arise as the result of a broken ankle. Gaye would end up paying the cost of medical services in the foreign country in that situation.
An exception is also made if the event occurs in Canada while en route between the continental US and Alaska and the Canadian hospital is closer – we will assume that this situation does not apply to Gaye’s broken ankle. Likewise if you live in the US and the foreign hospital is closer to your home than the nearest US hospital that can treat your medical condition There are some communities, such along the Alaskan Panhandle, where this situation applies.
So unless one of these exceptions applies, Gaye should expect to pay the full cost of her medical coverage – she is traveling and unless that travel is going through Canada on her way to Alaska then she is unlikely to receive any help from Medicare for those expenses. Gaye, prior to traveling, would be well advised to take out travel medical insurance in order to have coverage for these types of expenses. The reason is simple – hospitals even in the US have to opt into Medicare coverage and there are no hospitals outside the US that are able to do this.
If Gaye intends to do much traveling outside of the US, she may wish to look beyond Original Medicare. There may be a Medicare Advantage plan that offers some form of travel medical coverage, but these plans can vary quite a bit with respect to what they cover, so it would be worth shopping around. But Original Medicare is not going to be of much help for Gaye should she suffer from an injury in a foreign country, especially a non-life-threatening injury like a broken ankle.
References
Medicare.gov (2020) Website, various pages. Medicare.gov. Retrieved April 10, 2020 from https://www.medicare.gov
Social Security Administration. (no date). Website, various pages. SSA.gov. Retrieved April 10, 2020 from https://www.ssa.gov